C l i n i c a l E d u c a t i o n E x p e r ie n c e s o f P h y s i o t h e r a p y S t u d e n t s in a C l in ic a l S e t t in g f o r E l d e r l y A d u l t s A B S T R A C T : T h e p u r p o s e o f th is s tu d y w a s to a s s e s s a n d d e s c r ib e q u a li­ ta tiv e ly th e le a r n in g e x p e r ie n c e s o f p h y s io th e r a p y s tu d e n ts w ith in th e c o n ­ te x t o f a c lin ic a l e d u c a tio n s e ttin g w h e re s tu d e n ts le a r n t to p r o v id e c a r e f o r e ld e r ly a d u lts. D a ta c o lle c te d o v e r tw o y e a r s f r o m s tu d e n ts ’ d ia r ie s k e p t d u r in g th e b lo ck, a n d in d iv id u a l o r g ro u p in te rv ie w s, w ere a n a ly ze d . Two m a jo r th e m e s w ere v ita l to th e s tu d e n ts, n a m e ly c o p in g w ith d is a b ility a n d r e d u c e d fu n c t i o n a l a b ility in e ld e r ly a d u lts, a s w e ll a s d e a lin g w ith d e a th a n d d y in g . T h e s tu d y c o n c lu d e d th a t th e re is a n e e d f o r c lin ic a l in te g r a tio n o f th e c o n c e p ts o f c h ro n ic d isa b ility , d e a th a n d b e r e a v e m e n t in p h y s io th e r a p y e d u c a tio n . K E Y W O R D S : P H Y S IO T H E R A P Y , E D U C A T IO N , S T U D E N T S , O L D E R P E R S O N S , E X P E R IE N C E S AM O SUN SL (BSc Physiotherapy, PhD Physiology)1 1 Department of Physiotherapy, University of the Western Cape INTRODUCTION The increasing num ber o f elderly adults in South Africa requires that physio­ therapy students gain necessary skills in inform ation gathering, assessm ent, and treatm ent applied to geriatric patients. This calls for creative inclusion o f elderly adults in learning experiences for students in physiotherapy education programs. In the U nited States o f America, the prim ary purpose o f geriatric training at m edical schools was to improve the care o f the elderly by increasing their know l­ edge base and fostering interest in older patients of practitioners in every specialty (Barry 1994). A secondary goal was to interest some students in selecting geriatrics as a career. It is com m on practice for physiother­ apy educators and clinical supervisors to develop core-learning objectives for physiotherapy students to work towards when they em bark on clinical placements focusing on the needs o f elderly adults (Simpson et al, 1993). It is assum ed that several features o f these objectives distinguish them from those set for other areas of physiotherapy practice. The loss of function is usually gradual in elderly adults. Inevitably, there are those who would require long-term care as they becom e too frail to manage on their own (H arpur et al., 1994). Often these indi­ viduals also have m ultiple problem s associated with advanced age, and m eet­ ing their needs often presents challenges to students and qualified practitioners. Attempts at m eeting these needs seem to influence physiotherapy educators in the developm ent o f core-learning objec­ tives for physiotherapy students during geriatric clinical placements. Unfortunately, none o f the learning objectives seem to prepare students to cope with the experience o f relating to individuals who may suffer from chronic disability and lim ited function (Harpur et al., 1994). In addition, the objectives do not seem to prepare students to cope with patients who may encounter death due to old age or other causes. Physiotherapy students at University o f the Western Cape are often sent to a governm ent-subsidized residence for elderly adults in the southern suburb o f Cape Town. The residence offers long stay continuing-care accom m odation for three groups o f older persons, namely a frail care group, a nursing assistance group, and a fully independent group. The residence provides full time m edi­ cal and nursing care, in addition to physiotherapy and occupational therapy services. In the recen t past, the students expressed feelings o f shock and revul­ sion to the author on their experiences during on this particular geriatric clinical education block. In som e cases, students w ere reluctant to continue with the block. For some, it was the first time of interaction with “an old helpless person who died in spite o f all physiotherapy care” . The encounter with the death of som e clients seem ed to have raised questions about chronic disability, death and dying, and the fear o f death among the students. A strategy was therefore put in place to reduce the perceived concerns o f the students. Once a wqek during the geriatric block, the author had individual or group discussions during w hich students w ere en co u rag ed to express their feelings and thoughts openly. Two earlier studies focusing on the p hy sio th erap y edu catio n program in the U niversity o f the Western Cape iden­ tified b u rnout am ong the students (Amosun and D andle, 1996), and possi­ ble co n trib u tin g factors included in their experiences during clinical educa­ tion (Sim uzingili and Amosun, 1998). The concerns raised from the two earlier studies as well as the concerns expressed by students during past geriatric clinical blocks prom pted the present study. This study was therefore undertaken to assess C O RRESPO ND ENCE TO: P rof SL Amosun D epartm ent o f Physiotherapy U niversity o f the Western Cape Private Bag X I 7, Bellville 7535 E-mail: sam osun@ chs.uw c.ac.za Tel: (021) 959-2542 Fax: (021) 959-2804 SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 2 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) mailto:samosun@chs.uwc.ac.za and describe the learning experiences o f physiotherapy students within the context o f one clinical education setting where students learnt to provide care for elderly adults. The author proposed that physiotherapy students at the U niversity o f the W estern Cape were adequately prepared to face w hatever challenges they encountered in a geriatric clinical education setting. METHOD Research Setting A t the U niversity o f the W estern Cape, physiotherapy students enter an eight sem ester undergraduate program . Till the end o f 1999, the first four and a half sem esters were spent at the U niversity with lim ited exposure to the clinical environment. In the remaining semesters, students were expected to rotate through eight clinical education blocks spending four to five weeks in each block. The blocks included a geriatric block, a com m unity block, a general block (res­ piratory, orthopaedics, neurology), and a rehabilitation block (includes spinal cord injuries). The remaining blocks were paediatrics, outpatients, intensive care and an elective block. Students normally went through the geriatric block during their third year o f training, and were often in groups o f four students. Students were required to work under supervision for 40 hours a week while on the block. Procedure All students in the selected clinical faci­ lity were required to keep diaries about their experiences o f daily encounters with patients during the clinical educa­ tion block. A t the end o f the block, the students were also required to diarise a summary o f their experiences. In addi­ tion, individual or group interviews were conducted with the students towards the end o f each block at the clinical site, as a means o f block evaluation. A t the beginning o f the 1998 and 1999 acade­ m ic sessions, all 3rd year students were informed about the intention o f the author to obtain an overview o f the experiences the students encountered while on the particular clinical block. All the diaries o f students who agreed to take part in this study were collected at the end o f each block. A t the end o f the 1999 academic ses­ sion, the narratives in the diaries and end o f block interview s were analyzed retro­ spectively to identify recurring themes (Fagerberg, Ekm an 1998). In addition, the author utilized extracts from the stu­ d ents’ diaries, which were considered to be representative o f the views expressed by m ajority o f the students, to describe the experiences o f the students. Result B etw een 1998 and 1999, th irty-tw o students passed through the selected clinical facility, and 20 students (62.5%) subm itted their diaries to be analyzed. D uring end o f block interview s, the participating students (m ale and female) indicated that the block was not the first tim e they had opportunity to interact with older people. G oing through the diaries o f the students and listening to issues raised during individual o r group interviews, two m ajor them es appeared vital to the students. The first concern related to the ability o f the students to cope with chronic disability and reduced functional ability in elderly adults. There was a general perception am ong the students that, in spite o f the clinical diagnoses, m any o f their patients were helpless and suffering because o f neglect, and these perceptions seemed to have im pact on the students. One student summarized her experience: “M y experience in this block threw me o ff balance to begin with. M y fir s t p a tien t was incontinent an d it seem ed as i f no one really cared. I understand that the nurses have many people to attend to a n d that no one p erso n can get special treatment. I was aware o f the degradation that the p a tien t m ust have felt. I f in d it a tragedy that the patien t was subjected to hum iliating conditions on a daily basis. I fe lt extreme distress and wondered whether / could deal with this. ” A nother student reported: “M y f i r s t im pression w as one o f neglect a n d suffering, a n d though that has n ot changed, / have taken it upon m y se lf to a t least improve the quality o f life o f those fe w people that I work with. ” Unfortunately, the students expressed different degrees o f frustration in their attem pt at im proving the status o f their clients. The students set out and im ple­ m ent tre a tm e n t ob jectiv es based on the clinical diagnoses o f the clients, but expressed their own inadequacies as to w hat to do to alleviate the ‘helplessness’ o f their clients. O ne student summ arized the frustration thus: “I am getting fru stra te d by the lack o f progress with m y patients. I would like to overlook the lack o f progress and fin d some other way to assess whether or not what I am doing is having a positive effect or not. ” T he second m ajor challenge to the students was dealing with death and dying. S om e o f them en co u n tered patients who expressed the desire to die, and refused treatm ent. The students felt helpless in handling such cases. Students whose patients died reported that they felt “bad and hopeless” . Some students acknow ledged that their fear was related to their ignorance o f what to expect and how to know when a patient is dying. O nly four students had opportunity to see a dying patient, and the experiences m ade an im pact on them. One student vividly described her experience: “I heard a scream like a baby crying. One o f the night sisters, the doctor and assistant nurses appeared. / never saw a person dying in m y life. She was fig h tin g like anything, as i f she was going to survive. Yet it was the end f o r her. I was so shocked to see that she was dead whereas her eyes were still opened. To be calm is very im portant in such a situation, to think, to know w hat to do. A s a result, I co u ld not sleep well, and the fo llo w in g day I woke up with a terrible headache. I have to be calm in order to cope with real life. ” W hile m any students addressed nega­ tive aspects o f their experiences during the block, some students also com m ented 4 SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) on feelings o f excitem ent and discovery. An experience o f one o f the students is described below: “I was assigned a respiratory patient with CO A D (chronic obstructive airway disease). He was nebulized every m orn­ ing before breakfast. A t fir s t he needed to be nebulized, but as he improved I stopped. He dem anded it and though my culture expected me to obey older people, I refused. I explained to him the risks o f nebulizing. It was hard f o r me to draw the line with the patien t pleading, but it was a g ood learning experience f o r me to make a decision and stick by it. I have gained confidence in decision making through this experience. ” T he following com m ent sums up a sentim ent expressed by many students: “7 think that this block has been an incredible learning experience, and the m ost im portant lesson that I learnt is to treat patients as people, not conditions. I have been able to overcome many difficulties and have learnt a great deal, probably the m ost im portant aspect o f being a physiotherapist, which is the ability to treat people, not patients. ” DISCUSSION Physiotherapy educators have an obliga­ tion to train practitioners who will meet the needs o f the society that they will serve. In their attem pt to provide service to older persons, physiotherapy students in this study experienced certain chal­ lenges. It is therefore im portant that the needs o f the students in meeting these challenges should be identified, and appropriate solutions put in place to avoid increasing their levels o f stress (Amosun and Dantile, 1996; Simuzingili and A m osun, 1998). P hysiotherapy educators can only enhance learning by being sensitive to these needs while developing clinical objectives (Hayes et al., 1999). Ignoring these needs may lead to unsafe or ineffective practice. C oncerns about the needs may also influence students in their selection o f preferred clinical placem ents (Fagerberg et al., 1997). The issue o f chronic disability is o f p rim e im portance in phy sio th erap y practice, especially its im pact in elderly adults (Clarke 2000). Physiotherapists and physiotherapy students are often faced w ith ethical and psychosocial dilemmas. Clarke (1998) explained the phenom enon o f suffering in chronic disability when there is a threat to the “personhood” o f the client. Unfortunately, physiotherapists tend to apply treatm ent interventions to alleviate the symptoms o f chronic disability when in fact the client is really experiencing suffering. In such instances, the treatm ents are ineffective and the physiotherapist may incorrectly lose confidence in the efficacy o f a p a rtic u la r treatm en t technique. Clarke (1998) reported the need for im plem enting the concept o f suffering into assessm ent and treatm ent regimes. In the current study, w hile the students had som e skills in assessing the func­ tional limitations in chronic disability, the students were unable to appreciate the threat to the “personhood” o f their clients. It m ay be helpful to assist students to have a better understanding about the role that the phenom enon of suffering plays in chronic disability. This may better equip the students to assist their clients to attain their optimal rehabilitation potential. Physiotherapy students receive very lim ited system atic training in caring for dying people. The m ajority o f physio­ therapy education training focuses on technical skills. A sim ilar situation was rep o rted in the m edical edu catio n p rogram in O regon H ealth S cience U niversity (Bascom et al., 1999). Forty- two percent o f students who graduated betw een 1996 and 1998 never had the opportunity to care for dying patients. Preparing students to face the loss o f patients through suffering and death is not an easy task. The experiences reported in this study represented a poignant but emotionally draining aspect o f students’ clinical education experi­ ences, w hich make adjusting to death- related encounters a particular challenge for students. A clear im plication is the need for effective guidance and support to be provided by the system and by individual m em bers o f the teaching and clinical staff in im proving students’ coping m echanism. P h y sio th erap y students face their own fear o f death w henever they come to the bedside o f a dying patient. This fear m ust be confronted and reconciled before they can help others m eet death w ith dignity. Exam ining o n e’s attitude towards death is a difficult task that needs to begin in the student years when attitudes tow ards w orking w ith the dying are form ed. Barnard et al., (1999) rep o rted th at basic en d -o f-life care competencies are in five domains namely: (i) psychological, sociologic, cultural and spiritual issues; (ii) interviewing and com m unication skills; (iii) m anage­ m ent o f com m on symptoms; (iv) ethical issues; and (v) self-know ledge and self- reflection. M ost o f these com petencies are already included in physiotherapy education curricula, and physiotherapy ed u cato rs should id entify effective ways o f prom oting necessary awareness am ong students. A tim e to begin may be during hum an dissection in anatomy (H ancock et al., 1998). At the onset o f this study, the author proposed that physiotherapy students at the U niversity o f the Western Cape were adequately prepared to cope with all challenges encountered during the geriatric block. The findings suggest that the students were unsure in coping with chronic disability, dying and death. However, the generalization o f the results to other physiotherapy students and pro­ gram s should be done with caution since data was gathered from physiotherapy students from only one university. CONCLUSION It is not possible to equip physiotherapy students w ith all the practical skills that they are likely to need. Professional education curricula should extend beyond the learning o f discipline-specific skills to encom pass broader learning goals w hich w ill en ab le the students to function better within clinical environ­ ments. If physiotherapy educators deal adequately w ith the moral and psy ­ chosocial issues presented in the clinical education settings, they assist students to form ulate appropriate attitudes and behaviours towards patients. There is a critical need o f adequate and contem ­ porary clinical integration o f chronic disability, death and bereavem ent con­ cepts in physiotherapy education. SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 2 5 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) REFERENCES A m osun SL, D antile N D 1996 E valuating phy sio th era p y education at the U niversity o f the W estern C a p e - A re we gra d u atin g p h y sio ­ th erapists w ith the b u rnout syndrom e? 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S o u th A fric a n Jo u rn a l o f Physiotherapy, 54, 4, 10-14 Physiotherapists • W idest choice of Locum, P erm anent and Fixed-Term C o n tra c ts • Advice on: S ta te Registration UK Visas and W ork Perm its A ccom m odation Bank A ccounts • Top rates of pay • UK C P S M Registration F e e s reim bursed • FREE Holiday Pay Contact Bridget O ’F a rre ll BScOT in South Africa on (021) 423-3853 Fax: (021) 423-3855 E-mail: corinth@mweb.co.za London O ffice Toll Free 0 8 0 0 -9 9 -3 0 5 5 Fax: 0 9 4 4 20 8 2 0 7 6 89 4 E-M ail: p t@ co rin th .co .u k 6 SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) mailto:corinth@mweb.co.za mailto:pt@corinth.co.uk